This occasional newsletter is researched, written and edited by a group of concerned residents in Ealing, West London who want to preserve our NHS. We view the wholesale engagement of private, for-profit healthcare service suppliers as unnecessary, profligate and dangerous. Increased financial funding is what is needed in our NHS – not financial cuts, closure of vital services or privatisation.
44 Months To Go Until National NHS Costs Will Have Been Reduced by £1.83 Billion Every Month
£22 billion annual cost savings beginning in the Financial Year ending 31 March 2022 is the ACS/STP/Footprints/Simon Stevens FYFV/NHS England/UK Government target.
The first eight pioneer STP/Accountable Care Systems (ACSs), which will deliver these monumental savings, don’t commence until 1 April 2018. The other 36 STP/ACSs will clearly have shorter grant-aided pioneering periods until they begin the cost saving for real commencing 1 April 2021.
ACSs (ACOs generically) are completely untested in England. The concept (originating in the USA) is after all only some 10 years old. ACOs have tended to be much smaller than those about to be attempted here. Cost savings results in the USA have been mixed – as have ACO experiences in Spain and New Zealand.
Does anyone actually believe reaching this £22 billion cost saving target in FY 2021/22 is in any way possible? Isn’t this a massive ‘throw of the dice’?
In NHS NW London a much less ambitious cost saving project (healthcare only – no social care or healthcare and social care integration) has been unable to identify any cost savings whatsoever (FOI response 30 May 2017). This project, ‘Shaping a Healthier Future’ was designed in 2012 and has been in its implementation phase for over four years.
Who actually believed that such a target is/was desirable?
What is the point of creating publicly paraded performance targets which are ‘unhittable’?
Just what do these impossible-to-attain financial targets say about us as a nation, say about this government and say about all of us? ‘Cloud Cuckoo Land’ comes to mind. What kind of inspiration or role model is this for our children?
It seems to me to be a form of national self harming. Impossible goals in a society being increasingly populated by the poor, the disadvantaged, the home-alone elderly, the physically ill and disabled, the sick, the mentally ill and disabled and the vulnerable who are all finding daily quality of life increasingly impossible.
A terrible rumour is emerging from the ashes of Grenfell Tower. Allegedly, 40 people have been found dead in just one flat. Now this could have been a party in progress or it could have been that the flat was ‘home’ for 40 people. If the latter is true just how healthy was that? How is it that the Tenant Management Organisation (TMO), an arm of the Local Authority, allowed this density of living to exist? No doubt there was planning guidance which was aimed at stopping this. But that clearly did not work. Yet another ‘pie in the sky’aspiration.
No point in rules or edicts which are not able to be implemented.
The time for reform is now. But it won’t happen by creating and publicly trumpeting futile and unrealistic plans to reduce our annual national healthcare costs by 20% starting in just 44 months time.
A mentally and physically healthy society is a productive one.
Ealing CCG Enters ‘The Twilight Zone’ by Expecting Already Stretched Ealing GPs To Deliver The Long Awaited 2012 SaHF ‘Out of Hospital’ Services
Ms Neha Unadkat, Deputy Managing Director Primary Care & Integration, Ealing Clinical Commissioning Group and Ms Tessa Sandall, Managing Director, Ealing Clinical Commissioning Group have jointly authored a July 2017 ECCG Business Case for Primary Care.
In 2012, NHS North West London launched its ‘Shaping a Healthier Future’ (SaHF) programme. SaHF was/is all about cost savings allied to (page 8) ‘…changes that will improve care both in hospitals and the community…’. Page 36 of the SaHF explains ‘Proposals for delivering care outside hospitals’. SaHF, we were told on page 11, was ‘..at least a three year (programme)’
Well…here we are almost five years later and reading yet again about proposals for delivering care (that was in 2012 delivered in hospitals) Out of Hospitals (OOH).
Here are some headlines from the 115 pager:
+ ‘…improve the resilience of general practice..’
+ Delivery of 23 standards (!)
+ GPs will deliver paediatric phlebotomy (drawing blood from children), winter resilience and dementia contracts and ‘Out of Hours’ services
+ ‘The Strategic Commissioning Framework for Primary Care Transformation in London’ lists 17(!) service specifications for GPs
The bottom line is that GPs, for a bit more cash no doubt, will be expected to fill the huge gaps which will open up as beds and staff are cut in hospitals. This is going to be a disaster. Even the ECCG business case admits that:
‘Primary care in Ealing is under unprecedented strain, with a rise in the number of appointments and increasing numbers of practices who report that their current workload is unmanageable or unsustainable…the number of registered patients per FTE GP in Ealing is significantly higher than the London and England averages’.
‘The current GP workforce in Ealing is ageing and facing a ‘retirement bubble’ which has the potential to put the system under a strain’.
But a bomb shell exploded at the Ealing Council Health and Adult Social Services Standing Scrutiny Panel meeting on 26 July 2017. Out of the blue and buried inside the 422 pages of printed material for the meeting is on page 287 – ‘Commissioning a Lead Provider for Out of Hospital Care’. This is just for Ealing and the lead provider will take over in April 2018 WITH A TEN YEAR CONTRACT.
Now there are pages and pages of stuff on this but being brutal the question has to be asked:
Who or what mandated a ten year contract?
This duration is new to the Ealing healthcare scene. New GP surgery contracts , the ECCG contract , and the Healthwatch Ealing contract do not enjoy ten year tenures. My contention is that this ten year component has either come from Government or from private healthcare suppliers. If it’s Government the only future show in town will be an Accountable Care System (ACS) vehicle for OOH. Services. If the ten year requirement came from private healthcare suppliers it’s likely that exploratory talks have already begun with the likes of Virgin, HCI, BMI, Ramsay, Spire, Nuffield, United Health, UKSH, Care UK, or Circle.
It’s going to be very messy….
NHS Bosses Are Still Maintaining That Ealing Hospital is Not Closing
Our regional NHS bosses are clearly still confused about the massive differences between the well established concept of a full service hospital i.e. a District General Hospital (DGH) and the newly invented NHS North West London concept of a ‘Local Hospital’.
On the Ealing Hospital site, where the major development activities are the building of residential tower blocks, we still have a DGH. DGH features on site include adult A&E, Intensive Care consultants and beds, Operating Theatres and a total of 309 hospital beds.
By 2021, NHS bosses tell us that Ealing ‘Local Hospital’ will replace Ealing DGH. To be brutally honest keeping to time is not an NHS speciality so that date might just slip or it all might come about earlier. This ‘Local Hospital’ will apparently house GPs and nurses and offer some diagnostic, therapeutic, out-patient and day care services. It will offer an expanded ‘Frail/Elderly’ service for which 50 hospital beds will be available. That will be the sum total of beds in this New Age glorified First Aid Post.
The NHS has produced a terribly disingenuous leaflet dated July 2017 entitled ‘What You Need to Know About Ealing Hospital’. The scale of deception is so great that a detailed critique is probably unnecessary. I will distribute a scan of this leaflet when I distribute this newsletter.
Why can’t NHS bosses have the guts to tell the truth?
The much respected Leader of Hammersmith & Fulham Council Councillor Stephen Cowan recently summed up this semantic confusion between DGH and Local Hospital by stating:
‘It’s like having your home demolished only to have it replaced with a shed. And being told it is a ‘local home’.
15 Favoured Sustainability and Transformation Funds (STPs) Get £325 Million in Grants To Help With Their Building Works
On 19 July 2017, the Government and NHS England announced that 15 STPs will share £325 million for building works. The biggest winners include the STPs for Dorset, Greater Manchester, Cumbria, Derbyshire, Leicester/Leicestershire & Rutland, Nottinghamshire and Milton Keynes/ Bedfordshire & Luton. Here are some summary details of some of these STP grant winners:
Recently granted Accountable Care System (ACS) grant-aided status, Dorset STP will get cash for building Urgent Care facilities.
Greater Manchester STP
Another recent ACS grant winner, gets £50 million for concentrating facilities for urgent and emergency care at four hub sites across Greater Manchester.
Cumbria has won £30 to £50 million to build a brand new Cancer care unit at Cumberland Infirmary in Carlisle.
Up to £30 million is granted to ‘create an Urgent Care Village’ at the Royal Derby Hospital with GP services, a frailty clinic and mental health facilities’.
Leicester, Leicestershire & Rutland STP
£30 to £50 million for a 15 bed in-patient unit at Glenfield General Hospital to improve children’s and young people’s mental health service integration with other care services. Also Intensive Care beds expansion at University Hospitals of Leicester..
Another ACS grant-aided area – £10 to £15 million for across the board service expansion.
Milton Keynes, Bedfordshire & Luton STP
Yet another ACS grant receiver, this STP grant is for building a new Primary Care hub.
Worringly there are no explicit references to cash for building work associated with social care or the integration of healthcare and social care. Regionally there must be a concern that NHS North West London’s request for £513 million for building works features nowhere in this Government/NHSE announcement. The fact that the NHS NWL cash demand was/is under the aegis of its 2012 ‘Shaping a Healthier Future’ (SaHF) project will probably cut no ice with the bean counters. This is probably in spite of recent NHS evidence that NHS NWL is one of the more financially prudent STP footprints.
Secret NHS Cost-Cutting Plans Labelled ‘Capped Expenditure Process’ (CEP) Will Ration Care, Cut Staff Numbers, Close Hospital Wards and Possibly Hospitals
As part of a new national savings drive, the CEP will withhold grant-funding to those NHS bodies which fail to meet financial targets. Service shrinkage, extended waiting times, job losses, and bed/ward/hospital closure will surely follow.
‘The Guardian’ quotes the content of a leaked document which states that the CEP might lead to service reduction/losses at The Royal Free Hospital and Great Ormond Street Children’s Hospital. North Middlesex Hospital in Enfield is at risk of downgrade or closure.
NHS Still Rated the Best, Safest and Most Affordable Healthcare Service in the Developed World
The Commonwealth Fund (CF) health think tank has, for the second consecutive time, found the UK to have the best healthcare service in the developed world. This brilliance is even more remarkable given that at 9th out of 11 nations the percentage of GDP we spend on healthcare is only 9.9%. The US spends 16.6% of its GDP on healthcare and France 11.4%.
In the 11 individual categories UK came top in ‘safest care’, ‘care processes’, ‘affordable care’ and ‘most equitable care’. On the bad news front we came 10th out of 11 in ‘healthcare outcomes’. Survival rates for breast, bowel cancer and strokes are relatively very poor.
Someone Leaks the NHS Guidance to the Eight ‘Starter’ Accountable Care Systems (ACSs)
The authoritative Health Service Journal (HSJ) has got hold of a draft NHS guidance document for the eight pioneer, grant-aided ACSs. ACSs will be the future delivery vehicles for STPs. In just 44 months time an ACS world throughout England will deliver £22 billion savings on national, annual NHS costs…….. The phrase ‘pigs will fly’ comes to mind.
The guidance is laced with US management consultancy jargon. It requires the ACS pioneers to ‘assertively moderate demand growth’. I guess if you were talking about this in the pub you might express this as ‘don’t treat all those in need’. Also mentioned are ‘potentially ratings’. Understanding what that means is way beyond both my Intelligence Quotient and my Emotional Quotient.
Each ACS must pass various tests before February 2018 in order to get its grant cash and to attain ‘Full ACS Status’ as of 1 April 2018. But surely ‘Full ACS Status’ must mean an absence of grant-aid. Such stripping of financial support to the ‘ACS Super 8’ isn’t envisioned, apparently, till 2021. So, with respect, this ‘VIP’ type status is a case of form over content.
ACS s will only get their money if they identify who is ‘accountable’ at the ACS for ‘delivery and value for money’ and who will manage ‘financial; and outcome oversight’. ACSs must meet performance targets for cancer, urgent and emergency care, primary care and mental health. This will be interesting to behold, as currently NHS Trusts are largely consistently failing to meet existing performance standards. However I don’t know what the ACS performance standards are/will be.
In the HSJ review of the guidance there are no references to social care service, social care performance targets and healthcare/ social care integration. This must be a concern for all of us.
NHS Improvement will appoint a ‘lead regional director’ for each ACS. More jobs for the boys (and girls) no doubt. ACSs will soon surely have to become self-standing (not grant aided), private cost-slashing consortia with huge 10/15 year contracts, Unless primary legislation is enacted through Parliament, surely these £billion+ turnover corporates will just ignore some regional pen pusher ‘boss’.
The First Managing Director Appointed to Run an ACS
According to Health Services Journal (HSJ) Wendy Saviour has been appointed and is in post now as Managing Director, Nottingham Accountable Care System. Her role and status is somewhat similar to that of Jon Rouse who is Director of the Greater Manchester devolution area (so called Devo-Manc Health). HSJ say a similar ‘arrangement is being developed int Surrey Heartlands’.
Ms Saviour and Mr Rous were appointed and are employed by NHS England. This is a far cry from the grandiose ACO/ACP intentions trumpeted variously earlier this year and in 2016. What was envisioned then was the formation of private consortia of public bodies (NHS and Local Authorities), private organisations (GP Federations and private healthcare/social care companies), charities and voluntary bodies. These consortia/partnerships/networks would clearly have management boards who one might have thought would have procured their own CEO/MD. But no….we have micro-management from the healthcare side of the care institutions. So much for devolution and local, regional autonomy. Does NHSE and the Department of Health really believe in this ACO/ACS approach? Is this the solution mapped out five years ago at the World Economic Forum in Davos? Or is there at least one more iteration of the CCG/STP/ACO/ACP/ACS merry-go-round yet to come?
Could Greater Manchester (Devo-Manc Health) become a Cost-Cutting, Care Services’ Improvement, Healthcare/Social Care Integration ,STP/ACS Success Story?
I visit my home city on 15 -17 August 2017 to find out. Full details in our September 2017 newsletter. If anyone has any supporting evidence or even gossip on this topic, please email me.
CHPI Report Warns That Implementing STPs Will Mean Lack of Appropriate Staff and Volumes, Too Few Beds, Poor Elective Care and Care in General, and Dysfunctional Healthcare/Social Care Integration
Vivek Kotecha has authored an impressive Centre for Health and Public Interest (CHPI) report on likely STP outcomes, which was published in June 2017.. His background makes impressive reading in itself. Vivek has a BSc Economics (Hons) from LSE and is a Chartered Accountant. He worked as a manager at NHS Monitor and NHS Improvement, prior to which he was a management consultant with Deloitte for four years.
Vivek paints a worrying assessment on the impact that implementing the 44 STPs is likely to have on staff, beds, Elective care, Public Health, across the board healthcare, and the integration of healthcare and social care.
It’s a fairly quick read at 18 pages. Some of his conclusions:
‘There will be fewer hospital beds per population, fewer GPs and GP surgeries, more patients will be seen by less qualified staff, the availability of treatments for non-emergency conditions will be more limited and the eligibility thresholds for others will be raised. Rationing non-emergency care, the withdrawal of services and/or reducing cost by reducing quality will be the only options. There is strong risk that NHS care will diminish in both availability and quality. The risks to patient safety from overcrowding and understaffing will get worse. The situation will be aggravated if the reorganisation of services is itself insufficiently funded or poorly implemented’.
Vivek makes no reference to the STP delivery ‘mechanism’ – Accountable Care Systems (ACSs). NHS bosses are seemingly keen to keep ACS deliberations under the radar and many STPs make scant reference to them. With 1 April 2018 start dates for the eight ‘phoney’ grant-aided, four year ACSs and some other STP ACSs (theoretically), it will be some time before ‘forensic’ research can reveal whether ACSs could improve care and achieve significant cost savings.
More at http://chpi.org.uk
The 2014 NHS Five Year Forward View (FYFV): Do the Numbers Add Up?
In May 2017, CHPI’s Vivek Kotecha brilliantly and forensically analysed the 2014 FYFV financial figures and could not get them to add up. The financial modeling for all this is mind bogglingly complex for non-bean counters. First he analysed the ‘funding gap’ (popularly touted as £30 billion by 2020/21 – but according to Vivek it could be much higher than this) in the context of additional government funding and productivity and efficiency savings. Whether the funding gap can be closed or not, Vivek puts down to whether the expectation of projected 2-3% NHS annual efficiency savings are realistic.
This itself relies on some key assumptions, which are:
+ There will be sufficient funding for transforming service delivery
+ The growth in healthcare provided in acute hospitals will decline
+ Hospitals will make 2% cost savings every year
+ NHS pay restraint for permanent staff will continue
+ The total cost of agency staff will fall by 4% a year
+ Investments in Public Health and illness prevention will help to cut costs
+ The provision of social care will prevent patients being unnecessarily admitted to and kept in hospital.
He then goes on to examine what the implications are for the NHS if the above assumptions on closing the financial gap are wrong. His conclusion is:
‘… the STPs have to assume that the overall calculations made by NHS England within which they are operating are realistic – that the numbers add up. If this is not the case the plans will not work. Instead of the intended improvement in care there will be a decline in quality and access and a growing risk that services will collapse. Our analysis suggests that the numbers do not add up’.
More at http://chpi.org.uk
Lack of Ventilators and Nurses Is Causing Too Many COP Deaths
A report by The National Confidential Enquiry into Patient Outcome and Death has revealed that NHS patients needing Non-Invasive Intervention (NIV) oxygen are receiving ‘shocking’ levels of care.
353 NHS patients – many with Chronic Obstructive Pulmonary (COP) disease – were subjected to in-depth examination. The results show that four out of five patients were receiving ‘less than good’ care.
NIV oxygen is meant to reduce the risk of dying from 20% to 10%. However it’s ‘really troubling’ that the UK death rate is 34% – whereas in Spain it’s 18% and in France it’s 10%. Two out of five hospitals at some point have been unable to cope with NIV demand because of lack of a ventilator. Fewer than half of hospitals are able to provide the staffing ratios of one nurse to two NIV patients. Research also revealed that doctors were often ‘really poor’ at documenting patient use of NIV oxygen – probably because of under staffing.
More at www.ncepod.org.uk